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prayer and spiritual support at the free clinic

His Hands is one of the founding members of the coalition now known as My Care Community. The work began 3 years ago as a part of a grant, and the group was known as the State Innovation Model. However, last week members of Linn County gathered to celebrate the launch of My Care Community. Even though the grant is coming to an end, the work will continue on.

20 agencies are partnering together to be a part of a database that focuses on the social determinants of health and streamlines the referral process. Healthcare outcomes can be impacted by things like food access, stable housing, transportation to appointments, and home safety. If a client comes to a partner agency, he or she can be given a quick intake that asks direct questions about social determinants of health. The client can then give permission to be added to the system. Their medical information is never a part of the database, but agencies can then do inter-office referrals. Instead of handing the client a referral card and trusting that they will be able to follow up on the referral, agencies can enter a need, select an appropriate referral agency from the dropdown list, and a notification is sent to alert the other agency that a referral has been made to them. Then the employee at the other agency can follow up on the referral and document if the outcome was successful. Over time, this will help service providers to see what agencies the patient has already accessed, what referrals were unsuccessful, and what barriers may be chronic issues. There is also a notes section, so that community partners can relay important information, and the patient does not have to tell and retell his or her story to every service provider they meet with.

The work of My Care Community is the first of its kind in Iowa, and we are excited to be a part of it! Linn County Public Health has been an integral part of launching and maintaining the coalition. We are thankful to be a part of a community that cares for the marginalized and vulnerable.

Amy DeLay, Patient Advocate

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